Recurrent or Persistent Pneumonia

Lower Respiratory Tract

Dr T Avenant

Recurrent or Persistent Pneumonia

• Definitions– Recurrent pneumonia

• more than two episodes of pneumonia in 18 months

– Persistent pneumonia• symptoms that do not

clear within 14 days• radiograph that do not

revert to normal within 4-6 weeks

• Most common causes of recurrent pneumonia– PTB– foreign body aspiration– misdiagnosed or

inappropriately treated asthma

– HIV– bronchiectasis

Approach to recurrent pneumonia

• Localize disease– Clinical – X-ray

• Localized disease– most likely a local abnormality of a bronchus or lung

parenchyma– common causes

• TB (glands)• foreign body aspiration• localized bronchiectasis

– bronchoscopy and RT of the lung usually indicated

Approach to recurrent pneumonia

• Widespread disease– immune compromised group

• acquired (AIDS & NAIDS)• congenital immunodeficiency syndromes

– non-immune compromised group• aspiration syndromes• abnormal cough mechanism• abnormal mucus clearance• “fragile lung” after insult

Anatomic localized illness

• Narrowed airway– Extrinsic compression

• Lymph nodes– TB, Lymphoma,

Neoplasm• Vascular ring

– Bronchial wall• bronchomalasia, web,

stricture

– Endobronchial pathology

– Endobronchialpathology(continued)

• foreign body, TB granuloma, neoplasm

• Congenital lung lesions– Bronchogenic cyst– Congenital lobar emphysema– Lung sequestration

• Focal bronchiectasis

Widespread Disease with Immunodeficiency

• Acquired– NAIDS– HIV lung illness

• Bacterial pneumonia, TB, CMV, PCP

• Other opportunistic infections

– Candida albicans– Cryptococcus

neoformans• LIP• Lymphoma / Kaposi

– Immune suppression

• Congenital – B cell defects– T cell defects– Phagocyte defects– Complement defects– Combined defects

Widespread Disease with Normal Immunity

• Allergy– Undiagnosed asthma

(mucus plugs)– Eosinophil pulmonary

infiltrates

• Persisting lung infection - TB

• Recurrent aspiration– Sucking or swallowing

abnormalities– TOF– GOR

• Muco-ciliary clearance defects– CF, Immotile cilia

• Heart lesions– L to R shunting with

increased pulmonary blood flow

• “Fragile” lung– BPD, Post necrotizing

pneumonitis

• Interstitial pneumonitis

Approach to the child with recurrent pneumonia

• Step one– careful history– clinical evaluation

• Step two– localize disease

• clinical examination• CXR

– exclude common causes• TB work-up• foreign body aspiration• asthma• HIV

• Step three– diagnose & treat if possible -

if not– refer for specialist work-up&

treatment• for localized disease

– RT– bronchoscopy most likely

to be done• for widespread illness

– further specialist work-up depending on situation

Suppurative Lung Disease

BronchiectasisLung Abscess

Bronchiectasis

• Permanent destruction of bronchial walls and lung tissue due to chronic infection

• Mechanisms– Bronchial lumen obstruction

• TB glands, foreign body, pertussis– Parenchymal destruction from necrotizing pneumonia

• Bacteria: staphylococci, Klebsiella, anaerobes, tuberculosis• Viruses: measles, adenovirus

– Repeated respiratory infections• Malnourished, cystic fibrosis, generalized

immunodefficiencies, aspiration pneumonia, ciliary diskinesia

Clinical Picture

• History– Repeated visits or admissions with lower

respiratory infections– Productive cough

• Activity• Change in position

– Difficult in children– Haemoptysis rare in children

Clinical Picture

• Examination– Clubbing after + 1 year– Halitosis– Growth retarded– Wide spread crackles

and wheezes– Pulmonary

hypertension and corpulmonale

Diagnosis

• Clinical picture• Chest radiograph

– Non specific or– Area of opacification that fails to resolve– Honey comb appearance (small cysts)– Widespread destruction, fibrosis and loss of

volume• Computed tomography

Differential Diagnosis

Evaluate every patient with bronchiectasis for

• Sinusitis • Ciliary dyskinesis• Immunodeficiency• TB• Asthma• CF

• If not found, bronchoscopy for– Stenosis, strictures,

foreign bodies, tumours

– Bacterial cultures

Treatment

• Prevention– Immunization– Correct treatment of pneumonia– Correct treatment of foreign body inhalation– Early detection and treatment of TB

• Physiotherapy with postural drainage

Treatment

• Appropriate antibiotics• Immunized against influenza• Some benefit from bronchodilators• Surgery if

– Disease progression and– Unilateral– No pulmonary hypertension– Adequate lung function

Lung abscess

• Abscesses follow infection with:– Staphylococcus aureus– Haemophilus influenza– Klebsiella pneumoniae– Mycobacterium tuberculosis– Anaerobic infections– Streptococcus pneumoniae (rare)

• In children most often after aspiration of infected material

Lung abscess

• Clinical picture– Toxic, malaise– High swinging fever– Foul smelling sputum– Respond poorly to antibiotics– Amphoric breathing– CXR: cavity with fluid level

Lung abscess

Treatment

• Postural drainage• Intravenous antibiotics

– Penicillin– Cloxacillin– Aminoglycoside

• Exclude bronchial obstruction• Drainage